Healthcare Provider Details

I. General information

NPI: 1316330749
Provider Name (Legal Business Name): CENTRAL UTAH CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W STE 202
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-2367
  • Fax: 801-429-8015
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number9847128-1725
License Number StateUT

VIII. Authorized Official

Name: JED HARSTON
Title or Position: DIRECTOR OF MANAGED CARE
Credential:
Phone: 801-812-5012